Mental Status Assessment

■ IDENTIFYING DATA
1. Name
2. Gender
3. Age
a. How old are you?
b. When were you born?
4. Race/culture
a. What country did you (your ancestors) come from?
5. Occupational/financial status
a. How do you make your living?
b. How do you obtain money for your needs?
6. Educational level a. What was the highest grade level you completed in school?
7. Significant other
a. Are you married?
b. Do you have a significant relationship with another person?
8. Living arrangements
a. Do you live alone?
b. With whom do you share your home?
9. Religious preference
a. Do you have a religious preference?
10. Allergies
a. Are you allergic to anything?
b. Foods? Medications?

GENERAL DESCRIPTION
Appearance
1. Grooming and dress
a. Note unusual modes of dress.
b. Evidence of soiled clothing?
c. Use of makeup?
d. Neat; unkempt?
2. Hygiene
a. Note evidence of body or breath odor.
b. Condition of skin, fingernails.
3. Posture
a. Note if standing upright, rigid, slumped over.
4. Height and weight
a. Perform accurate measurements.
5. Level of eye contact
a. Intermittent?
b. Occasional and fleeting?
c. Sustained and intense?
d. No eye contact?
6. Hair color and texture
a. Is hair clean and healthy-looking?
b. Greasy, matted, tangled?
7. Evidence of scars, tattoos, or other distinguishing skin marks
a. Note any evidence of swelling or bruises.
b. Birth marks?
c. Rashes?
8. Evaluation of client’s appearance compared with chronological age.

Motor Activity
1. Tremors
a. Do hands or legs tremble?
• Continuously? • At specific times?
2. Tics or other stereotypical movements
a. Any evidence of facial tics? b. Jerking or spastic movements?
3. Mannerisms and gestures
a. Specific facial or body movements during conversation? b. Nail biting? c.
Covering face with hands? d. Grimacing?
4. Hyperactivity
a. Gets up and down out of chair.
b. Paces.
c. Unable to sit still.
5. Restlessness or agitation a. Lots of fidgeting. b. Clenching hands.
6. Aggressiveness
a. Overtly angry and hostile. b. Threatening. c. Uses sarcasm.
7. Rigidity
a. Sits or stands in a rigid position. b. Arms and legs appear stiff and unyielding.
8. Gait patterns
a. Any evidence of limping?
b. Limitation of range of motion?
c. Ataxia?
d. Shuffling?
9. Echopraxia
a. Evidence of mimicking the actions of others?
10. Psychomotor retardation
a. Movements are very slow. b. Thinking and speech are very slow.
c. Posture is slumped.
11. Freedom of movement (range of motion)
a. Note any limitation in ability to move.

Speech Patterns
1. Slowness or rapidity of speech
a. Note whether speech seems very rapid or slower than normal.
2. Pressure of speech
a. Note whether speech seems frenzied. b. Unable to be interrupted?
3. Intonation
a. Are words spoken with appropriate emphasis?
b. Are words spoken in monotone, without emphasis?
4. Volume
a. Is speech very loud? Soft? b. Is speech low-pitched? C. High-pitched?
5. Stuttering or other speech impairments
a. Hoarseness? b. Slurred speech?
6. Aphasia a. Difficulty forming words. b. Use of incorrect words.
c. Difficulty thinking of specific words. d. Making up words (neologisms).

General Attitude
1. Cooperative/uncooperative a. Answers questions willingly. b. Refuses to answer
questions.
2. Friendly/hostile/defensive a. Is sociable and responsive. b. Is sarcastic and irritable.
3. Uninterested/apathetic a. Refuses to participate in the interview process.
4. Attentive/interested b. Actively participates in interview process.
5. Guarded/suspicious a. Continuously scans the environment. b. Questions motives of
interviewer. c. Refuses to answer questions.

EMOTIONS
Mood
1. Depressed; despairing
a. An overwhelming feeling of sadness. b. Loss of interest in regular activities.
2. Irritable a. Easily annoyed and provoked to anger.
3. Anxious a. Demonstrates or verbalizes feeling of apprehension.
4. Elated a. Expresses feelings of joy and intense pleasure. b. Is intensely
optimistic.
5. Euphoric a. Demonstrates a heightened sense of elation. b. Expresses
feelings of grandeur (“Everything is wonderful!”).
6. Fearful a. Demonstrates or verbalizes feeling of apprehension associated with real
or perceived danger.
7. Guilty a. Expresses a feeling of discomfort associated with real or perceived
wrongdoing. b. May be associated with feelings of sadness and despair.
8. Labile a. Exhibits mood swings that range from euphoria to depression or anxiety.

Affect
1. Congruence with mood
a. Outward emotional expression is consistent with mood (e.g., if depressed, emotional
expression is sadness, eyes downcast, may be crying).
2. Constricted or blunted a. Minimal outward emotional expression is observed.
3. Flat a. There is an absence of outward emotional expression.
4. Appropriate a. The outward emotional expression is what would be
expected in a certain situation (e.g., crying upon hearing of a death).
5. Inappropriate a. The outward emotional expression is incompatible with
the situation (e.g., laughing upon hearing of a death).

THOUGHT PROCESSES Form of Thought

1. Flight of ideas a. Verbalizations are continuous and rapid, and flow from one to
another.
2. Associative looseness a. Verbalizations shift from one unrelated topic to
another.
3. Circumstantiality a. Verbalizations are lengthy and tedious, and because of
numerous details, are delayed reaching the intended point.
4. Tangentiality a. Verbalizations that are lengthy and tedious, and never reach an
intended point.
5. Neologisms a. The individual is making up nonsensical-sounding words, which
only have meaning to him or her.
6. Concrete thinking a. Thinking is literal; elemental. b. Absence of ability to
think abstractly. c. Unable to translate simple proverbs.
7. Clang associations a. Speaking in puns or rhymes; using words that sound
alike but have different meanings.
8. Word salad a. Using a mixture of words that have no meaning together;
sounding incoherent.
9.Perseveration a. Persistently repeating the last word of a sentence spoken to the
client (e.g., Ns: “George, it’s time to go to lunch.” George: “lunch, lunch, lunch, lunch”).
10. Echolalia a. Persistently repeating what another person says.
11. Mutism a. Does not speak (either cannot or will not).
12. Poverty of speech a. Speaks very little; may respond in monosyllables.
13. Ability to concentrate and disturbance of attention a. Does the person hold
attention to the topic at hand? b. Is the person easily distractible? c. Is
there selective attention (e.g., blocks out topics that create anxiety)?

Content of Thought
1. Delusions (Does the person have unrealistic ideas or beliefs?)
a. Persecutory: A belief that someone is out to get him or her is some way (e.g.,
“The FBI will be here at any time to take me away”).
b. Grandiose: An idea that he or she is all-powerful or of great importance (e.g.,
“I am the king … and this is my kingdom! I can do anything!”).
c. Reference: An idea that whatever is happening in the environment is about
him or her (e.g., “Just watch the movie on TV tonight. It is about my life”).
d. Control or influence: A belief that his or her behavior and thoughts are being
controlled by external forces (e.g., “I get my orders from Channel 27. I do only what the
forces dictate”).
e. Somatic: A belief that he or she has a dysfunctional body part (e.g., “My
heart is at a standstill. It is no longer beating”).
f. Nihilistic: A belief that he or she, or a part of the body, or even the world does
not exist or has been destroyed (e.g., “I am no longer alive”).

2. Suicidal or homicidal ideas

a. Is the individual expressing ideas of harming self or others?
b. Does the individual have a plan?
c. Does the individual have access to the identified means for his or her plan?
d. How strong is their intent to die?
3. Obsessions
a. Is the person verbalizing about a persistent thought or feeling that he or she is
unable to eliminate from their consciousness?
4. Paranoia/suspiciousness
a. Continuously scans the environment.
 b. Questions motives of interviewer.
c. Refuses to answer questions.
5. Magical thinking a. Is the person speaking in a way that indicates his or her
words or actions have power (e.g., “If you step on a crack, you break your mother’s
back!”)?
6. Religiosity a. Is the individual demonstrating obsession with religious ideas and
behavior?
7. Phobias a. Is there evidence of irrational fears (of a specific object, or a social
situation)?
8. Poverty of content a. Is little information conveyed by the client because of
vagueness or stereotypical statements or clichés?

PERCEPTUAL DISTURBANCES
1. Hallucinations. (Is the person experiencing unrealistic sensory perceptions?)
a. Auditory. (Is the individual hearing voices or other sounds that do not exist?)
b. Visual. (Is the individual seeing images that do not exist?)
c. Tactile. (Does the individual feel unrealistic sensations on the skin?)
d. Olfactory. (Does the individual smell odors that do not exist?)
e. Gustatory. (Does the individual have a false perception of an unpleasant
taste?)
2. Illusions
a. Does the individual misperceive or misinterpret real stimuli within the
environment? (Sees something and thinks it is something else?)
3. Depersonalization (altered perception of the self)
a. The individual verbalizes feeling “outside the body”; visualizing himself or
herself from afar.
4. Derealization (altered perception of the environment)
a. The individual verbalizes that the environment feels “strange or unreal.” A
feeling that the surroundings have changed.

SENSORIUM AND COGNITIVE ABILITY

1. Level of alertness/consciousness
a. Is the individual clear-minded and attentive to the environment?
b. Or is there disturbance in perception and awareness of the surroundings?
2. Orientation. Is the person oriented to the following?
a. Time. b. Place. c. Person. d. Circumstances.
3. Memory
a. Recent. (Is the individual able to remember occurrences of the past few
days?)
b. Remote. (Is the individual able to remember occurrences of the distant past?)
c. Confabulation. (Does the individual fill in memory gaps with experiences that
have no basis in fact?)
4. Capacity for abstract thought
a. Can the individual interpret proverbs correctly? • “What does ‘no use crying
over spilled milk’ mean?”
IMPULSE CONTROL
1. Ability to control impulses. (Does psychosocial history reveal problems with any of the
following?)
a. Aggression. b. Hostility. c. Fear. d. Guilt. e. Affection. f. Sexual feelings. ■ JUDGMENT
AND

INSIGHT
1. Ability to solve problems and make decisions
a. What are your plans for the future?
b. What do you plan to do to reach your goals?
2. Knowledge about self
a. Awareness of limitations.
b. Awareness of consequences of actions.
c. Awareness of illness. • “Do you think you have a problem?” • “Do you think
you need treatment?”
3. Adaptive/maladaptive use of coping strategies and ego defense mechanisms (e.g.,
rationalizing maladaptive behaviors, projection of blame, displacement of anger)